ORLANDO, Fla. -- Like a certain segment of the physician population contemplating retiring early instead of learning electronic health record (EHR) systems by the 2015 federal deadlines, a segment of hospital coders might quit instead of learning ICD-10 codes, which will replace the current ICD-9 codes in the United States on Oct. 1, 2013.

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More news about ICD-10 codes

A new survey of 770, mostly experienced, coders released by kForce Inc., a management staffing firm that counts health care among its verticals, found that 36% of medical coders are concerned about how to get the necessary training in ICD-10 codes, and 3% are flat-out worried about their future. (Loosely defined, mostly experienced means someone more than 35 years old with 11 or more years in the profession.)

Nearly two-thirds of respondents to the survey were relying on their employers to train them in ICD-10, but only 27% have started it. Technology plays a big part in how the medical coders will succeed, because 66% of respondents feel most comfortable with online training. When asked about which areas they will need to be trained in, rules and regulations came first (66%), but second (44%) was learning the new technology that would support ICD-10 codes.

One statistic, however, will have chief financial officers worried about their bottom line. About 0.4% of coders had already left the field when they filled out the survey, and another 5% plan to leave before the transition to ICD-10 codes.

Extrapolating the information over U.S. Bureau of Labor Statistics figures, kForce estimates those departures will leave 8,625 medical coder positions vacant, among roughly 175,000 positions in the U.S. health care system. And, if the survey results are a true reflection of national trends, that does not take into account the additional 14% who still are wavering about staying or going before ICD-10 codes become the health care standard.

What is driving them away? "It's a combination of technology, ICD-10 and the complexity around it, and the complexity of the rules and regulations," said kForce Healthcare Group President Peggy Pricher in an interview at the annual convention and exhibit of the American Health Information Management Association, or AHIMA. "Remember Y2K and what a big deal that was? This is much more significant."

Medical coders to be in demand

Experienced coders keep productivity up and the revenue flowing into hospitals from payers, Pricher and kForce Vice President Amy Simpson said. However, working in health care after the transition to ICD-10 codes will be analogous to moving to a foreign country and learning a new language.

Demand for medical coders will be intense in this period of transition. kForce already has booked many qualified coders for work in 2013, and is looking to train less-experienced coders to fill what looks to be a large backlog. As schools incorporate ICD-10 codes into their curriculum, and graduates work their way through the industry, the shortage should gradually ease.

That projection does not help hospitals now, however. Losing experienced coders to retirement can affect a hospital in many negative ways. One potential negative effect is on the bottom line, including claims denied from being improperly coded, and uncoded services "lost" in the process by less-experienced coders. Despite more and more processes in health care going digital, coders possess institutional knowledge about a hospital and its payers that cannot be programmed into a software system.

"Every [patient] chart has a personality," Pricher said. "If you're a veteran coder, you know what kind of personality the chart has, based on the physicians that were involved. . . . [Y]ou learn how to read that."

In ICD-10 transition, where CIOs, EHR systems can help

CIOs can help, Pricher and Simpson said, by advocating such technologies as computer-assisted coding and voice transcription tools. These can aid directly in the transition to ICD-10 codes, creating efficiencies to spur productivity during the time invested in the codes' steep learning curve.

Remember Y2K and what a big deal that was? [ICD-10] is much more significant.

Peggy Pricher, group president, kForce Healthcare

Indirectly, CIOs can have a much bigger influence, however. The key to effective coding and reimbursement starts with complete and relevant documentation, and that relies on high-quality, accessible EHRs, Pricher and Simpson said.

"Coders are quite dependent on the level [of detail] and the specificity of the documentation," Simpson said. "How are physicians going to assimilate some of the changes" associated with new EHR systems?

To that end, IT staff can help ease the burden on coders -- and keep them around longer -- with thorough EHR training that puts an emphasis on detailed data capture by health care practitioners, Pricher said. When doctors and nurses understand the system's features in depth, and become comfortable using many of them in their daily workflow, documentation benefits. Starting now on a slow ramping-up, they said, will ease the 2013 transition to ICD-10 codes, making it less of a big-bang event and more of a smooth process.

"ICD-10 isn't just a coding issue, it's pervasive through the system," Pricher said, with physicians as well as representatives from accounting, reporting and billing getting involved. As they plan for integrations with EHR systems and to comply with the Health Information Technology for Economic and Clinical Health, or HITECH, Act and the Health Insurance Portability and Accountability Act (HIPAA), she added, "they need to take into account the effects ICD-10 will have on them."

UPDATE: Making ICD-10 implementation a business initiative

Recognizing that ICD-10 implementation is falling behind, in December 2010 the Workgroup for Electronic Data Interchange (WEDI) revised its timeline for making the transition to ICD-10 codes. Since the end date cannot change, the timeline's start date was pushed back from January 2009 to a more realistic August 2010.

Still, WEDI acknowledged that some health care providers have been so overwhelmed with implementing EHR, meeting meaningful use and updating HIPAA business associate agreements that they have been unable to address ICD-10.

ICD-10's impact on IT is hard to understate. For Orlando Health, the move to ICD-10 codes is expected to require changes to at least 72 IT products, from software to databases to communication systems. To address this, the organization has assembled a 23-member steering committee to examine how ICD-10 implementation will affect those IT systems, as well as business processes, training and communication management.

Alexander Veletsos, Orlando Health's CTO, said health IT leaders must position the transition to ICD-10 codes as a business initiative aimed at improving care quality and operational efficiency, not just an information technology issue.

One way to do this is to emphasize how ICD-10 codes can improve clinical documentation -- specifically, creating coded problem lists and electronic discharge summaries (both of which also happen to be meaningful use requirements). In this case, clinicians should be standing alongside CIOs to spearhead the ICD-10 project, identify key milestones and, as a means of maintaining momentum, celebrate those milestones once they have been reached.

That has been the approach for Christiana Care, where the health system’s vice president for patient safety and quality, rather than the chief financial officer, is the ICD-10 "champion." When ICD-10 codes are made a key part of quality, safety, patient registries and clinical documentation, improved reimbursement will happen automatically, said Kathy Westhafer, program manager for clinical information at Wilmington, Del.-based Christiana Care, the largest private employer in Delaware.

Peggy Lynahan, the organization's ICD-10 program manager, said that getting physicians to document accurately at the point of care is not as hard as it seems. After all, she said, they know what type of care they have provided, and that care is consistent with ICD-10 codes. It's just a matter of making sure the codes are captured.

Having previously implemented e-prescribing and computerized physician order entry (CPOE), Christiana Care's physicians are therefore familiar with bringing computers into clinical workflows. Bringing ICD-10 codes into that computerized workflow will "close the loop," Lynahan said, adding, "We're in a position where the physicians are asking for this."

Westhafer agreed: "I feel like the time is right to give them other tools to enhance what they are already doing."